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welcome to the boardroom of the National.Transportation Safety Board I am Robert.some Walt and I'm honored to serve as.the chairman of the NTSB and joining us.today are my colleagues on the board.vice chairman first Landsberg member.earl wiener member jennifer comedy today.we meet an open session is required by.the government in the Sunshine Act to.consider the crash involving a Lear 35 a.while approaching New Jersey's Teterboro.Airport on May the 15th 2017.today is the first board meeting that.the NTSB has had of this year had it not.been for the five-week partial.government shutdown this would have been.the fourth board meeting that we have.held and furthermore this board meeting.for this product would have been a month.earlier in the accident that we're.deliberating today the pilots allowed.the aircraft to stall and they.subsequently lost control of the.aircraft as they were turning on the.final on a poorly flown circling.approach the airplane struck a.commercial building and parking lot and.was destroyed by impact forces in a.post-crash fire and tragically both.pilots lost their lives on behalf of my.colleagues on the board and the entire.NTSB we'd like to offer our sincerest.condolences to the families and friends.of those pilots the purpose of our being.here is to learn from this so that.others don't have to go through what you.have gone through the accident occurred.on a positioning flight operated by.trans-pacific air charter a part 135.operator part 135 with the Federal.Aviation Regulations governs on-demand.charter operations as well as air.medical and commuter flights the nuance.here is because this was a positioning.flight one without revenue passengers or.cargo on board the flight was conducted.under part one under part 91.general operating rules of the Federal.Aviation Regulations however the.accident does raise important questions.about what can be done to improve the.safety of part 135 operations part 121.of the Federal Aviation Regulations.governs what most people think of when.they hear the term commercial aviation.regularly-scheduled air carrier flights.that said if part 135 aviation had the.same tools as part 121 we might not be.here today one more time if part 135.aviation has the same tools as part 121.we might not be here today.the accident might not have occurred.improve the safety of part 135 aircraft.operations as well it's on our most.wanted list of transportation safety.improvements and this accident.illustrates the potential safety.benefits applying knowledge gained in.part 121 investigations and adopting.solutions already introduced in part 121.flight 2 part 135 operations and we.realize that part 121 and 135 can't do.everything the same way but we do.believe that there should be an.equivalent level of safety between the.two.this accident highlights the problem of.procedural non-compliance.according to Trans Pacific standard.operating procedures or SOPs the.second-in-command who was the flying.pilot had not yet gained the experience.necessary to fly the airplane yet.the captain of the flight disregarded.company policy and allowed this.second-in-command to be the flying pilot.both pilots had broken with procedures.in other ways the pilot command had not.obtained a weather briefing for the.accident flight or conducted an adequate.pre-flight planning and the pilots did.not brief the approach during the flight.furthermore performance deficiencies.that had been noted during the pilots.initial training were not being.monitored by the.company for reoccurrence safety programs.used by part 121 operators might have.detected such deficiencies more directly.part 121 air carriers are required to.have programs that ensure that.performance deficiencies are corrected.to date such programs are not required.for part 135 in a former life while.serving as an airline pilot I was also a.member of the flight operational Quality.Assurance team or folklore team in that.role we looked at minor procedural.deviations in non accident flights now.as an NTSB board member I've seen too.many cases where accidents occurred.including today's case at hand that are.due in part to procedural non-compliance.and a lack of professionalism one thing.I can tell you is that you might be.certain with certain aptitudes but.nobody is born a professional it takes.work in constant discipline.professionalism is a mindset that.includes hallmarks such as precise.checklist you should usage precise.call-outs and precise compliance with.SOPs and regulations those traits are.conspicuously absent on this flight the.pilot commands use of expletive or one.such disconcerting symptom now when.transcribing the sounds recorded on a.cockpit voice recorder the NTSB denotes.expletives using a hashtag symbol there.were so many hashtags in this transcript.it reads like a social media feed 131.expletives in a half an hour that.averages to one expletive every 14.seconds that's just one symptom of a.shocking lack of professionalism another.far more problematic issue was the.flight crews disregard for procedural.compliance.following SOPs puts a pilot in a.position to succeed they also form a.strong defense against accidents years.ago my colleague Earl Weiner led a study.where he and his team analyzed over 100.airline accidents they found that the.highest-ranked accident prevention.strategy was for pilots to follow.standard operating procedures the.highest ranked accident prevention.strategy is following procedures.operators need to detect whether their.pilots are complying with SFPs.but part 135 operators do not have all.the tools they need to ensure procedural.compliance in one such tool is safety.management systems or SMS as the FAA.describes it it's a top-down.organization wide approach to managing.safety risk and ensuring the.effectiveness of safety safety risk.controls it includes systematic.procedures practices and politic and.policies for the management of risk.another such tool flight data monitoring.or FDM FDM programs look at routine non.accident data for deviations or unsafe.practices like focal programs in part.121 but such programs are not currently.required in some part 135 operators even.lack basic data recording capabilities.needed to support FDM the accident.flight was also an example of poor crew.resource management CRM Dunwell results.in effective communications in workload.management in adherence to SOPs however.during the accident flight the captain.had to extensively coach the essa the.second-in-command as the flying pilot.while the captain was also having to.perform his responsibilities as pilot.monitoring and as you'll hear he need he.did neither well and both pilots lacked.situational awareness here too there's a.difference between the implementation of.CRM in part 1:21.versus part 135 now I want to make this.point there are many very good part 135.operators but part 121 hop operators.have tools that many 135 operators don't.have the safety of part 135 aviation can.be improved in a moment investigators.will provide the details of this.accident flight and as they present.their findings bear in mind now this.flight might have been different if.lessons from part 121 accidents had been.applied staff have pursued all avenues.in proposing findings of probable cause.and recommendations to the board now the.order of the meeting will be the staff.will present will make presentations I.think there are so three presentations.they will make those presentations and.then we own the staff we own the board.will question staff we will also propose.and vote on any amendments necessary to.ensure that the report is we adopted.today truly provides the best.opportunity to enhance safety our public.docket available at NTSB gov contains.almost 1,100 pages of additional.information including photos and post.accident photo interviews once finalized.the accident report will be available on.the NTS b--'s website so managing deputy.managing director paula Slezak if you.would kindly introduce the staff thank.you and good morning.Thank You mr. chairman a few.announcements before we begin I kindly.request for those here in the boardroom.if you've not done so already please.silence your mobile phones or other.electronic devices there are two exits.in front of the auditorium on either.side of the Dyess went to the left one.to the right go down the stairs out the.door and follow the illuminated exit.signs to depart the facility you may.also exit to the rear of the auditorium.where you entered and pretend if you do.exit that way proceed out the glass.doors go up the stairs and exit straight.ahead through the large glass.stores turn to your left and walk to the.end of the street and the event of an.emergency please walk cookie to the.nearest exit and make your way to the.outside following the instructions of.NTSB staff do not return to the.boardroom until instructed to do so if.you have any questions or concerns.please see any NTSB staff person seated.at the panel this morning unless.otherwise noted our staff members of the.office of aviation safety on the first.row starting to my right is Dana Schulz.acting director of the office of.aviation safety to her right is Jim.Suleiman the investigator in charge for.this accident to his right is captain.David Lawrence operational factors to.his right is dr. bill bramble he'll.cover human performance and to his right.is Tim birch who will cover vehicle.performance behind mr. birch is Jeffrey.Marcus acting chief of the safety.recommendations division to his left is.Don Ike who will cover meteorology to.his left is Betty Koscheck who will.cover air traffic control issues to her.left is Jim Ritter director of the.Office of research and engineering to.his left is Kathleen Isola who is our.general counsel and to her left is.Darlene hatchet who's director of the.office of safety recommendations and.communications behind miss hatchet is.Lynne Spencer who will be covering.visuals and conducting the timing for.the board meeting today to her right is.Adam Gerhart so we'll cover.airworthiness issues to his right is.Greg bow sorry who will cover.maintenance records to his right is.Shaun Payne who will address any CBR and.sound spectrum analyses issues and to.his right is Karen Stein from the.writing and editing division in the.office of aviation safety.this morning's presentations will begin.with opening comments by Dana Schultz.good morning chairman Zumwalt vice.chairman Landsberg and members of the.board as the chairman indicated we are.once again discussing an accident that.highlights why the board has included.improving the safety of part 135.aircraft operations on the NTS b--'s.most wanted list for 2019.notably staffs report today will.highlight findings involving some of the.very same safety to finish deficiencies.we identified in Prior fatal part 135.accidents specifically widespread.non-compliance with company standard.operating procedures and oversight.deficiencies the end result of that from.2000 to 2002 - excuse me 2015 the NTSB.investigated seven major accidents.involving part 135 on demand operators.with findings related to pilot.performance tragically those accidents.cost the lives of 53 people and.seriously injured another four people.part 135 operations often involve.carrying passengers for hire and we.believe that more needs to be done to.ensure that all part 135 operators have.adequate safety protections in place for.the flying public in a minute staff from.the NTS b--'s office of aviation safety.will discuss the specific findings from.our investigation of yet another tragic.accident involving a part 135 operator.that took the lives of two more people.during a positioning flight that.resulted in an unstable eyes digital.approach into Teterboro Airport in.Teterboro New Jersey as the staff will.discuss flight data monitoring programs.as part of a safety management system.could have played a role in preventing.this accident just as they could have.done in preventing the other fatal.accidents noted earlier OFDM and SMS.complement each other.yielding data that can be used to.improve procedural compliance as well as.identify and mitigate operational.hazards before they lead to an accident.for those part 135 operators who have.voluntarily implemented SMS and FDM.programs we recognize them for their.proactive safety leadership however.sadly we continue to see that when.operators rely on the minimum FAA.requirements which currently lack SMS.and FDM program requirements safety risk.remains unnecessarily high we're here.today to encourage the industry and the.FAA.to raise the bar on safety for part 135.operations chairman Zumwalt mr. Jim.silliman the investigator in charge will.now present an overview of the accident.report under consideration by the board.today thank you good morning today we'll.discuss the details of the Learjet 35.aid that crashed while flying into.Teterboro Airport in Teterboro New.Jersey on may 15 2017 an animation of.the accident about 10 minutes in length.was created using information from the.ground radar the airplanes airplanes.enhance ground proximity warning system.the airplanes cockpit voice recorder and.air traffic controls recordings of.conversations between the captain and.air-traffic controllers the animation.depicts the flight of the airplane from.takeoff until the accident occurs the.animation also contains a short video of.the accident was captured by a security.camera located near the accident site.the security video is shown at the end.of the ten-minute animation for those of.you in the boardroom if you do not wish.to listen to the ATC transmissions or.view the video you may exit the.boardroom now and those watching by.webcast may wish to turn down the volume.and turn away from their display please.play the animation.on May 15 2017 about 3:20 9:00 p.m..Eastern Daylight Time a Learjet 35 a.departed control flight while flying the.ILS runway 6 circled to land runway 1.approach at the Teterboro Airport in.Peterborough New Jersey the captain and.the second command died no one on the.ground was injured the airplane was.destroyed by impact forces and.post-crash fire the part 91 positioning.flight departed the Philadelphia.International Airport Philadelphia.Pennsylvania on 4 Teterboro about 3 or 4.p.m. the straight-line distance from.Philadelphia to tear de borough was.about 80 nautical miles and the flight.lasted about 25 minutes the flight to.Teterboro was the crew's third and last.planned trip for the day.company had designated the second.command as a second to man zero which.meant that he could only perform pilot.monitoring duties company policy.required the captain to always be the.pilot flying when flying with a.second-in-command.however the cockpit voice recording.indicated the second command was the.pilot flying for all but the final 15.seconds of the accident flight for most.of the flight the captain instructed the.second-in-command in flying the airplane.including flight basics such as altitude.and airspeed the cockpit voice recording.also indicated that the crew failed to.complete any of the required checklist.during the flight contrary to published.guidance and company manuals the captain.filed an instrument flight rules flight.plan which requested altitude of 27,000.feet for a planned distance of about 120.nautical miles with an estimated time in.route of 28 minutes the crews plan route.is depicted in white air traffic control.cleared them to fly at 4,000 feet they.were cleared for a slightly shorter.route shown in blue the white arrow.indicates the airplanes position and.heading and the magenta line shows the.airplanes actual ground track during the.climb and level off at 4,000 feet the.captain instructed the second command to.keep the airspeed below the FAA.restriction of 250 knots for flight.below 10,000 feet.radar data indicated that the crew.exceeded the airspeed restriction.multiple times during the 25-minute.flight about eight minutes into the.flight when the airplane was only about.54 miles from the Teterboro Airport the.captain requested a higher altitude not.realizing how close they were to the.airport the controller denied the.request sane and require the airplane be.turned away from Teterboro to be.resequenced for five Q Delta alpha.unable higher I would have to spend you.back around and sequence you with the.rest of the traffic going in.Peterborough about two minutes later.when the airplane was about 48 nautical.miles from the Teterboro Airport air.traffic control began vectoring the.airplane for the ILS runway 6 circled.the runway one approach to the Teterboro.Airport 5 - Delta alpha New York.approach they will consummate of - 9 - 7.5 fighting zero - zero like your ILS 604.one two Niner seven five in Newark we.are tuned up to half of flying zero -.zero vector is 6 over 1 the cockpit.voice recording indicated that the.captain questioned the reason for the.vector is an assigned approach because.he told the second command that they.were still hundreds of miles away about.26 seconds later air traffic control.gave a descent clearance their 2.5.percent of 93,000 after acknowledging.that clearance the captain realized that.they're close to Teterboro and stated.that they would be a Teterboro in 10.minutes.air traffic control began providing.radar vetters to intercept the localizer.inbound course 30 2015 is zero Niner.zero intercept of six localizer contact.New York approach one to seven point six.[Applause].while attempting to join the localizer.the second command mistook the Newark.International Airport for Teterboro and.told the captain that he had the runway.in sight the airplane flew through the.course of zero six zero degrees and.shortly after air traffic control stated.the following virgin mm experience at.the local was for 5 mm there's your to.delve a left turn 20 honey P George you.got it you got the airplane turn left.and intercepted the localizer inbound.air traffic control then directed the.flight to the Waypoint bings.Learjet to Delta alpha just go to go to.things can you do that things and some.local autistics by 2015 while the.airplane was inbound to being the second.command attempted to transfer the.controls to the captain but the captain.did not respond and the second command.continued to fly the approach air.traffic control cleared the airplane for.the approach Learjet 4 5 2008 miles from.dings crosswinds at 2,000 feet uh.dollars from my six circle only one okay.clear the Iowa six circle one things.2005 to Delta alpha the pilots did not.conduct an approach briefing before.beginning the approach contrary to.publish guidance and company manuals the.captain stated to the second command.that they be circling to runway 1 and.would be descending to the circling.minimums of 760 feet the Teterboro.Airport is located in either Newark John.F Kennedy and LaGuardia airports to.avoid conflicts with those airports.aircraft landing at Teterboro when the.wind is from the north are often.vectored to approach from the west then.circled to land to the north on runway 1.the white line shows the ground tracks.of previous aircraft flying the same.circling approach that was assigned to.the accident airplane on the day of the.accident the wind was from the Northwest.at 16 to 20 knots gusting to 32 knots.the initial approach clearance issued to.the airplane was to fly the ILS runway 6.a circle to annoy one airplane is flying.this approach were typically told to.circle act or B which was 3.8 nautical.miles from the approach end of runway 6.after Tory they would turn right and.visually fly toward MetLife Stadium and.then turn left to line up with Renault.a1 about three minutes after receiving.the approach clearance air traffic.control instructed the flight to do.three things one contact Teterboro tower.to cross dandy at 1500 feet three circle.at or be rigid to Delta alpha contacted.about terrible at 0.5 she crosses and E.400 feet circle of 40 all right and a.few hundred feet square B 95 for $50.00.dan deed 1500 feet to Delta 2015 all of.my details happen the flight crew.acknowledged these instructions but they.able to do all three first they did not.contact the tower second the airplane.crossed Andy at 2,000 feet instead of.1500 feet third they did not turn after.OB from this point on the movement of.the white airplane symbol and radio.communications occur in real-time as.airplane crossed or be the captain.continued to instruct the second command.improperly directing him to descend to.the minimum descent altitude of 760 feet.while the airplane continued straight.toward runway 6 instead of turning right.at tour B and proceeding visually to the.runway.one and a half minutes later the crew.still had not switched to the tower at.radio frequency until told a second time.by air traffic control to delta alpha.contacted about our 9555 for my to.develop the captain continued to.instruct the second command to descend a.750 feet instead of contacting the tower.say for five to ten thousand q to.prepare yeah we're off and certainly not.one not to go papa.Julie r45 to death when 360 r1 6 cus 3 2.1 anyone continued traffic building.musicians how to delta alpha the.airplane continued toward the airport as.the captain instructed the second.command to stop the descent.they're to death out there anyone quit.when it's a Trekkie now we're gonna be a.TV agent for pi G Delta alpha clear line.one when the airplane was about 1.nautical miles from the end of runway 6.the tower questioned the crew about the.turn he's letting five dogs down saying.it's not that turn yes sir we're doing.right now Fort Dix top top while.starting to turn to the right the second.command told the captain your flight.controls but the captain did not respond.the airplane lost 300 feet in the turn.and the enhanced ground proximity.warning system sounded 500 feet and the.sync rate pull up the second command.asked the captain to take the flight.controls again and finally the captain.took the controls directed the second.command to watch the airspeed and began.a high bank left turn to runway one.during the turn the second command.called airspeed four times the captain.called out stall as the second command.agreed and repeated airspeed twice the.enhanced ground proximity warning system.sounded sync rate pull up a security.camera captured the airplane as it.impacted the ground at a right bank.angle of about 125 degrees the airplane.crashed in the parking lot less than one.mile southeast of the Teterboro Airport.about 15 seconds after the captain took.the controls this is an aerial view of.the impact point at the wreckage path.and the parking lot where the airplane.crashed runway 1 can be seen in the.background this is an aerial view of the.wreckage debris path staff found that.there are no three impact structural.engine or system failures although the.accident flight was a part 91.positioning flight trans-pacific is a.part 135 operator and staff identified.the following issues related to the.safety of part 135 operations which is.currently on our most wanted list of.safety improvements many part 135.operators lack flight data monitoring.programs and safety management systems.also the FAA does not have a system to.ensure that operators have programs in.place to identify pilot non-compliance.with standard operating procedures we.also identified that transmission.didn't have a program to monitor pilots.with demonstrated performance.deficiencies and the FAA lacks specific.guidance for part 135 crew resource.management training and leadership.training for upgrading captains at part.121 135 and 91 K operators the.presentation by captain Lawrence and dr..bramble will address these issues.additionally we identified that.transpacific had not incorporated the.manufacturer recommended approach speed.wind additives in their operations.manual staff has proposed a.recommendation to include this wind.additive in Learjet 35 a operations.manuals in order to reduce the risk of a.stall in weather conditions conducive to.rapid and possibly unexpected wind.changes I would like to acknowledge.staff who participated in this vennett.investigation staff was assisted by.party representatives from the FAA.trans-pacific air charter Bombardier.Honeywell aerospace and the national air.traffic controllers is Jeff sociation.chairman soon well this concludes my.presentation captain David Lawrence will.discuss operational issues good morning.during the investigation we determined.that the flight crew was properly.certificated and there was no indication.that the flight crew was impaired by.medical conditions alcohol or other.drugs.however as mr. Solon explained we found.other issues I will discuss the pilots.background in training.the captain's decision to allow the.second-in-command or si si to fly the.airplane and the pilots pre-flight.planning and in-flight actions including.the pilots execution of the approach.into Teterboro I will also discuss the.methods that part 135 operators.including transpacific in the FAA could.identify non-compliance with standard.operating procedures or SOPs according.to the training records both pilots had.difficulties during initial company.training executing circle to land.approaches and the si si experienced.difficulties in basic control of the.Learjet.post-accident interviews with both.pilots simulator instructors and.previous employers confirmed the.concerns about the pilots performance.trans-pacific was aware of the pilots.training deficiencies and approved.additional training for both pilots.which they subsequently passed however.despite the company's knowledge of the.pilots training difficulties they were.paired together following their training.with no process to monitor their.subsequent performance or identify and.correct any continued deficiencies staff.believes that part 130-135 operators.should establish programs that monitor.the performance of pilots who had.demonstrated deficiencies during.training and is proposed of.recommendation in this area.trans-pacific have a defined policy to.have SICS gain experience in the cockpit.before they could manipulate the.controls of an airplane as the pilot.flying or PF new SICS including the.accident si si were not permitted to.operate as the pilot flying whether on.revenue or positioning flights however.contrary to company policy for the.accident flight the captain allowed the.si si to be the pilot flying and the.captain was the pilot monitoring the.captain's decision to have the si si.serve as pilot flying placed both pilots.in unfamiliar roles and interfere with.the normal division of duties between.the pilot flying and pilot monitoring.regarding certain tasks such as making.standard call-outs and initiating.checklists in addition the si sees.performance and basic flying tasks was.weak as evidenced by difficulties he.experienced with aircraft control.throughout the flight and the captain.provided extensive coaching which.distracted him and reduced his capacity.for performing the role of pilot.monitoring thus the captain's decision.to have the si si serve as pilot flying.resulted in degraded crew performance.other actions on the day of the flight.were also contrary to company procedures.the accident occurred on the third and.final scheduled flight of the day.records indicate that the captain.checked the weather at Teterboro prior.to the first flight of the day but there.was no evidence that he reviewed the.weather before departing on the accident.flight almost nine hours later in.addition the flight plan to Teterboro.filed by the captain requested altitude.of 27,000 feet which was incompatible.altitude for the short 28 minute flight.from Philadelphia indicating that Korea.devoted little attention to pre-flight.planning and that they did not have a.clear understanding of the flight route.in distance and the time pressure that.they would face when the airplane was 48.miles in 18 minutes from Teterboro air.traffic control told the crew to expect.the instrument landing system or ILS.runway 6 approach to runway 1 the CVR.transcript indicated that the captain.was uncertain about the approach the.controller reference but the crew did.not seek clarification from ATC this.would have been an opportunity for the.crew to brief the approach as required.by company procedures but the approach.briefing was not performed because the.crew failed to conduct an approach.breathing the navigation radios were not.properly set for the approach and the.distance measuring equipment was not.tuned to identify multiple points on the.approach so the crew had to figure out.the approach in real time the lack of an.approach briefing and improperly tuned.navigation equipment led to crew.confusion about the airplanes position.relative to approach waypoints and.difficulty complying with the approach.vertical profile which ultimately led to.a late initiation of the circles in that.circle go and maneuver this slide shows.airplane tracks based on FAA radar data.before the accident.56 airplanes flew the same approach to.Teterboro as the accident airplane those.airplane tracks are shown in green and.the airplane track for the accident.flight is shown in magenta also shown as.the tour B intersection which is the.final approach fix for the approach for.B was located 3.8 nautical miles from.the approach end of runway 6.at that point flights begin maneuvering.toward runway 1 as shown by the magenta.flight track the accident airplane flew.past tour B and did not start the right.circling turn until the aircraft was.less than one mile from the approach end.of runway 6.besides failing to brief the approach.the pilots did not complete any.checklist during the flight in the final.seconds of the approach the captain took.control but failed to execute a girl.go-around when the airplane was no.longer in a position to make a.stabilized approach to runway 1 all of.these errors were contrary to company.SOPs SOPs are widely recognized as a.basic element of safe aviation.operations in our and effective.countermeasure against operational.errors however because this flight crew.failed to hear to numerous SPS during.this flight the pilots were ill-prepared.to conduct the approach in to Teterboro.transpacific did not have a means to.identify this crews non-compliance with.SOPs and the company had no way.determined with no way to determine.whether this or any crews previous.operations were conducted in accordance.with SOPs pilot non-compliance.non-compliance with SOPs has been a.recurring issue in accident.investigations involving part 135.operators and improving the safety of.part 135 aircraft flight operations is.now part of the NTS b--'s most wanted.list of transportation safety.improvements the NTSB has been.advocating for programs to address pilot.non-compliance with SOPs flight data.monitoring or FD Em's systems installed.on the aircraft and FDM programs.designed to evaluate operational data.can provide valuable information to.allow an operator to detect trends of.non-compliance with procedures and.correct deviations from company SOPs in.addition increased fa oversight through.its safety assurance system or SAS.help identify those part 135 operators.such as trans-pacific that did not.monitor their pilots compliance with.SOPs because staffs investigation.determined that the accident operator.would have benefited from flight data.monitoring and increased fa oversight.through its SAS program staff proposes.reiterating three recommendations in.this area these recommendations were.initially issued in 2016 as a result of.our investigation into an accident in.Akron Ohio involving a part 135 operator.in summary safety could be improved if.part 135 operators provided an.additional oversight and training for.pilots with known performance and.training deficiencies to ensure that.such deficiencies are appropriately.addressed and corrected in addition as.this and other accidents have shown part.135 operators could benefit from flight.data monitoring programs and increased.fa oversight through its SAS program to.ensure pilot compliance with SOPs this.concludes my presentation.dr. bramble will now discuss the human.performance issues associated with this.accident good morning I will be.discussing the adequacy of existing FAA.guidance for part 135 crew resource.management training lack of leadership.training for upgrading captain's and a.lack of a safety management system.requirement for part 135 operators.according to the FAA is risk management.handbook CRM training emphasizes.situation awareness communication skills.teamwork task allocation and.decision-making within a comprehensive.framework of standard operating.procedures CRM trainings been required.for all part 135 pilots since March 2013.and part 135 pilots CRM skills are.developed through mandatory initial and.recurrent training during the accident.flight the crudest.guarded numerous SOPs and exhibited poor.planning and communication which led to.high workload and degraded situational.awareness.thus the flight crews teamwork was less.than optimal and did not represent.effective CRM the FAA requires part 135.operators to provide CRM training on.eight specific CRM topics trans-pacific.CRM training which consisted of a.twenty-seven slide presentation.referenced all required topics.however the training did not explicitly.state the importance of adhering to SOPs.for effective teamwork a major.deficiency in observed in this crew.trans-pacific training materials.highlighted the negative effects of.excessive workload but the training did.not discuss the impact of planning.briefing and decision-making on workload.and time management.another deficiency observed in this crew.the materials did emphasize crew.briefings but standard crew briefings.were omitted during the accident flight.in short trans-pacific CRM training did.not adequately address some important.aspects of CRM and it was ineffective at.producing desired behaviors in some.areas that the training did address.although the FAA requires part 135 CRM.training programs the FAA does not.provide adequate guidance indicating how.part 135 operators should train the.eight required CRM topics the guidance.that the FA provides is geared towards.part 121 CRM training programs in part.135 operators who train in accordance.with partland 21 requirements for.example part 121 CRM guidance makes.extensive reference to line oriented.flight training which is not common in.part 135 training programs FAA research.has identified factors that influence.CRM training effectiveness and this.research could be used to develop.guidance to help part 135 operators.implement effective CRM training.programs such guidance is needed and.staff has proposed a recommendation in.this area.the next issue that my presentation.covers involves the ineffective.leadership shown by the captain during.the accident flight compliance with.company SOPs pertaining to pre-flight.planning and approach briefing would.have improved this cruise performance as.crew leader the captain was responsible.for reinforcing compliance with SOPs as.a means of managing crew workload and.avoiding errors by not doing so he.demonstrated for leadership a review of.trans-pacific CRM training program.revealed that it did not adequately.address a captain's role as crew leader.especially as that pertained to.reinforcing SOP compliance a review of.the captain's employment history.indicated that before he was hired by.Trans Pacific he had not served as a.part 135 captain and no evidence.indicated that he had received formal.leadership training to prepare him for.the leadership responsibilities.associated with an upgrade to captain we.have noted deficiencies in captain's.leadership in previous accident.investigations including the 2009.accident involving Colgan Air flight.3407 in Clarence Center New York and we.have open recommendations in this area.that staff proposed for reiteration the.final subject of my presentation.involves safety management transpacific.had a Safety Officer but no SMS or other.formal safety program to address safety.risks an SMS requires operators to.incorporate formal system safety methods.into their internal oversight programs.such a program could have identified and.mitigated the hazards found during this.accident investigation including those.associated with an unauthorized si si.acting as pilot flying the pairing of.pilots with a history of training.difficulties and inadequate staffing for.the company's progressive si si.qualification program our agency has.recognized the value of SMS and we have.previously recommended that the faa.broaden SMS requirements to include part.135 operators staff proposes that.recommendation.and for reiteration as well in summary.safety could be improved by requiring.CRM training guidance that appropriately.addresses the needs of part 135.operators also the safety of operations.conducted under part 121 135 and 91 K.could be improved by requiring.leadership training for upgrading.captains in addition requiring safety.management systems for part 135.operators would provide a means for.incorporating formal system safety.methods into company internal oversight.programs this concludes staff.presentations well thank you I want to.thank you for those informative and.concise presentations also I thought the.animation was superb so thanks to all.who have been involved in that will now.begin with the board member questions.beginning with vice-chairman Landsberg.Thank You mr. chairman.not quite sure who to direct this.question to but it was very illustrative.that out of 56 approaches that were done.prior to the accident.we determined that at least eight were.not aligned with the runway by 500 feet.above ground level which is what we.normally define as a stabilized approach.in Veeam of the visual conditions it's.early in the warning for math but that.works out to about 14% and ice maybe.there were more so it seems like this.might be a moderately complicated kind.of an approach just curious.would there be any opportunity for maybe.a little more guidance from ATC to.reinforce the fact that people should be.starting the approach a little bit.sooner it went really quickly of at.least on the initial clearance about the.circle runway six circle to one and.there was no guidance that that was done.at tour B that came later I don't know.if this makes any sense or not but any.comments on that.vice-chairman Allah.deferred the air traffic control portion.of that question to miss Koshi but as.far as from a pilot standpoint this.particular approach we did take a look.at the certification standards and.flight testing for the circle approach.and it met all criteria and all turf.criteria so it wasn't any different than.any other circling understand but one.thing to bear in mind that the the.approach in this case was essentially.the ILS they were shooting the ILS to.get to the four B intersection based on.the air traffic control Clarence at that.point it becomes a visual approach.understand not a circle approach and I.defer the air traffic control and their.assistance to misko sure well I.and I I think the captain was fixated on.on the fact that he was asking the.second-in-command to descend to the high.F are circling minimums which just goes.along with the fact that he really.wasn't come on I don't think we need to.pursue this any farther.misko Shaikh again a little early for.math but looking at the Lear 35 flight.manual the ref speed was 119 knots and.also the guidance is that one is to.maintain about 20 knots above that while.they are getting the aircraft.established prior to let's say 500 feet.so that comes out to roughly about a.hundred and forty knots the wind factors.were 15 gusting to 30 roughly which.would be an eighth not additive gust.factor which gets us close to about a.hundred and forty eight knots or 150.knots before getting aligned with the.runway does that sound about right to.you that that's correct.if those calculations were to assume.using the Lear jet I've already a.guidance for wind additives what we.found in the investigation is that they.you're correct they were supposed to fly.bereft plus 20 which would have been.hundred thirty-nine for their flight all.the way around the pattern until they.were aligned with the runway but.transpacific did not incorporate any of.the win.guidance that was in the afm does the.company SOPs take precedence over the.airplane flight manual well operators.when they when they develop an airplane.or produce an airplane they're required.to have an airplane flight manual and.operators when they take deliver that.aircraft they're encouraged to develop.their own general operating or pilot.handbook incorporating a lot of the.material that's in that AFM some of the.AFM material must be in the company.operating manuals like certain.limitations certain required procedures.but guidance material similar to the.wind additive that was just suggested.they say they suggested adding half the.gust factor into it and wasn't required.to be in their operating room that that.additive is pretty standard across the.industry and it would seem like there.would be some it would be worth some.discussion to figure out if that should.be something that should be required.I'll defer the rest of my questions till.later Thank You mr. chairman thank you.vice chairman I'm member whiner I'd like.to follow on for a moment the circling.approach discussion have some of the.part 121 carriers avoid circle of land.approaches we didn't pull all the 121 s.as far as that back I can't tell you.that many part 121 operators have.multiple limitations and circle.approaches they may not necessarily ban.the circle approaches but they may.require circling approaches be conducted.in VFR conditions a thousand foot.ceiling and three miles visibility so.what are some of the inherent problems.with circling approaches from an.operator standpoint you just don't do.them that often that's one of the.limitations you see them in training but.you don't see them that often there's.also limited guidance as far as.navigation it becomes a visual approach.that at that point and since it's not.trained as often they only see it in.training.that's one reason some operators decide.- or at least put additional limitations.on circling in thank you dr. bramble the.carrier year trans-pacific had no SMS in.place what would an SMS have done for.them had they had a complete SMS in.place well as this as I mentioned during.my statements it might have detected.some of the risk factors that we.identified like the fact that their.progressive qualification program for.their SICS really wasn't working as.intended which set up an incentive for.the the P ICS to basically make the.decision as to when the si si should fly.as opposed to the company check pilots.and standards folks another important.aspect of SMS is if you have a flight.data monitoring program in place as we.also recommended it would provide a.mechanism for developing mitigation.strategies and following up on whether.those are effective so the flight data.monitoring is part of an SMS is that.correct correct yes it would be part of.the safety assurance component and that.consists of not only just the device on.board the airplane together in flight.data but also all of the processes.related to what you do with that data.afterwards exactly now.we focused on Friday monitoring in the.121 world we also add to that ASAP.what would ASAP have done for them for.them a PSAPs another safety assurance.mechanism that allows organizations to.detect risks in their operation it's.information that's volunteered by flight.crews that might not otherwise be.extracted by quantitative flight data.monitoring technologies so there's a.maturity model for SMS all the way from.just at the lower.stage introduction all the way to.continuous improvement is that something.that can be put in place rapidly or is.it something that takes a long time to.put in place it does take time to evolve.a fully functioning SMS and that's why.the FAA has classified sms's in terms of.stages of maturity so this is something.that really reflects the culture of the.organization because the culture needs.to be developed as you develop the.processes and implement the processes.summary yes now mr. chairman I'll yield.the remainder of my time Thank You.member whiner and member Hamid I'm sorry.there's a problem with my mic first of.all thank you very much I thought I.thought this report was fantastic you.all did a great job and thank you for.taking the time to brief me and a number.of times and as answering my questions.on on the report so I appreciate the.time you provided captain Lawrence can.you talk a little bit more in detail.about the pilot and pilots and the.second end commands training and the.difficulties they had in training yes.their training was down at CAA CAE semi.flight it was a training center both.pilots were scheduled about a year close.to once they were first hired for.recurrent training the captain's.difficulties were primarily with he had.to be trained to proficiency on certain.items like vor approaches CRM steep.turns basic maneuvering he also had to.find efficiencies in circle and.maneuvers which required him to get it.he was.scheduled for two sim sessions one.warm-up sim and then a check ride and he.was required three additional Sims to.get through the training the.second-in-command had multiple basic.aircraft control deficiencies that were.noted by the instructors he couldn't.even start the engines when he first got.in and he had already been rated on the.aircraft and had experience on it he had.basic aircraft control altitude heading.air speed controls issues and he also.had circle and proficiency issues he was.scheduled for a five-day footprint with.three sim sessions and needed an.additional four sims to get proficient.and passed the training was.trans-pacific made aware of the training.difficulties yes we looked at.correspondence between CAE and the.company and they were made aware of the.the pilots both pilots performance.deficiencies and they both in both cases.they approved the additional training so.they were aware did they know about.concerns from previous employers they.they did do a prea which is the pilot.records Information Act a background.check on the copilot or the.second-in-command and they received the.material from him however that material.was met the requirements of prea but.they didn't go beyond that to find out.and ask questions like we did during the.investigation we found out that that.company was actually about to perform a.performance review an evaluation on the.second command based on his weak.performance as a pilot.it wasn't transmitted through the prea.so they weren't aware of that because.they hadn't documented that previous.operator hadn't documented that material.the captain's material his priam.background check they requested of his.previous employer but they never.received it and thus they never had an.opportunity to evaluate that.documentation that was required before.they put him into service we did an.evaluation ourselves of if they had.received that prea and it would have.been benign information there wasn't any.performance issues.with this previous employer but that.Priya information never got to the.trans-pacific and did well first should.these two have been paired together from.league from a FA standpoint the FA are.sore the Code of Federal Regulations.there wasn't anything that prevented.them from being paired together there.are pairing limitations in part 135 and.135 point 4 pilots are not to be paired.if they have less than 75 hours each.there's also limitations for the.co-pilot if he is less than 100 hours in.the type the captain needs to make all.it take offs and landings under certain.conditions like contaminated runway.windshear things like that but both.these pilots had far in excess of the.flight time for any of those limitations.so there was absolutely no limitations.from a regulatory standpoint what we do.in the report is say based on their.deficiencies they probably should have.been reviewed and those deficiencies.considered before pairing them together.and really quickly did trans-pacific.ever audit or observe in flight.operations of the crew no they did not.thank you and Mohammed II thank you very.much.captain Lawrence as you pointed out the.second command on this flight had a.record a training record of poor poor.performance in listening to the cockpit.voice recorder as you and I did last.week I noticed that he was having.trouble controlling speed do you you.recall and I've got I counted it do you.recall how many times the captain.reminded him to keep his speed under.control I don't have the exact count but.it was numerous times yeah it was a 12.according to my account and I think I.read that in the report as well 12 times.in a 25-minute flight now in your.experience as an airline captain how.often did you find that someone had to.be reminded of their speed.well basic altitude altitude controlled.air speed heading control those are.basic maneuvers in flying an aircraft.and one thing a challenge for this.copilot was that this airplane didn't.have auto thrust so he wasn't relying on.autopilot or the autothrust exactly I.think that just he had performance had.problems with basic airmanship speed.altitude control he had the autopilot.engaged.and yet so really all he had to watch.was the speed and yet 12 times in a.25-minute flight he had to be reminded.to keep the speed under 250 knots or.bump it up to 250 knots the flying.distance and I went in and filed a.flight plan.macht flight plan with flight plan comm.yesterday and the flying distance was 86.miles direct line distance 80 miles but.via their route of flight Medina Victor.3 Solberg Teterboro 86 miles now just.doing the simple math and by the way.that there's there's no such thing as.simple math but as a rule of thumb we.would calculate it to sin saying three.times the altitude so if he was at 20 if.he was planning a flight at 27,000 feet.that would mean that he'd have to begin.his descent 81 miles out but yet the.flying distance was only 86 miles what.does that tell you right there a lack of.pre-flight planning lack of situational.awareness anything else yeah as we.allude to it in the report it was an.incompatible altitude obviously and when.he filed a flight plan through this.program that he did like you said it was.would have given him 4,000 feet as a.cruise altitude so he manually entered.that in why he did that we really can't.get into his head and understand why but.it does show that he didn't really think.about the the route before he followed.it you yourself have a lot great deal of.experience operating in and out of the.Northeast very busy airspace and it's a.short flight 25-minute flight are there.things that they.could have done ahead of time to help.them get ahead of the game like loading.the approach things like that no.absolutely I could have actually briefed.what they anticipated what the approach.is before they even left Philadelphia.there Rosen nothing restricting that the.workload that there was this flight had.dictated that somebody needed to the.crew needed to get together before they.even started the engines on this and.talk about this so you can call the ATIS.and there it is right there.you get on your cell phone and call the.Teterboro ATIS and find out before you.even leave what they're doing program.the FMS pre-brief the approach if I had.a short flight like from Greensboro.Charlotte do all that on the ground and.they could have done that but they were.behind before they even started the.engines I talked about procedural.compliance and we certainly did see.widespread procedural non-compliance I.have my cited the study that member.wayno did years ago you didn't think I.was paying attention and Kuala Lumpur in.1993 when you gave that paper but I've.referred to it many times following.procedures is a great accident.prevention strategy but data from Llosa.low sedated and we've quoted this in our.accident reports before the crew members.who intentionally deviated from standard.operating procedures or three times more.likely to commit other types of errors.mismanage more errors and find.themselves in more undesired aircraft.situations compared to those flight crew.members who did not intentionally.deviate from procedures and I think that.says a lot right there about the.importance of following SOPs.vice-chairman is all yours for our air.traffic specialist miss Koscheck.as the chairman has properly pointed out.this crew started in a hole before they.ever got going in terms of being behind.the aircraft if once they got airborne.they recognized that things weren't.going as well as they should have and.speed limit below 10 is 250 could they.have just said to ATC hey can we slow.down to 200 knots and can you seek with.sequence us that way so we can get a.little more time to get caught up to.things.would that cause a major problem they'd.have made the request they more unlikely.would have gotten it ok so just because.it'll go that fast doesn't mean you have.to fly it that fast right okay.reading the party submission by.trans-pacific they claim not to know.what the pilots were doing I think we've.we've had some discussion there and we.have a recommendation for monitoring.crew behavior how difficult is is that.to do and also even for 121 I don't know.that many many companies are monitoring.their cockpit voice recorders we see.sterile cockpit violated after the fact.all the time so I'm just curious as to.you know how we might approach that we.do have one past recommendation.involving the monitoring of audio.recordings in the cockpit I think mr..Marcus could best address that but in.terms of other avenues crew behavior and.interaction is monitored in a variety of.ways as member Waner mentioned earlier.there's the ASAP process where crews can.self-report risks and hazards there's.also at big airlines there are standards.committees and professional committees.that are run by the airline and the.unions where if there are problematic.individuals they can they can be.referred to that committee for.exploration but refer to mr. Marcus on.the the audio recording monitoring wreck.the past investigation it's a result of.the Colgin accident after that occurred.Colgan Air Lines wanted to start.monitoring the cockpit voice recorders.to look for instances of sterile cockpit.it's not the only thing that we were.looking for but it a good example of the.type of information that would get there.was a great deal of resistance we should.a recommendation to the FAA to enable.the collection of all data sources that.would be part of some sort of flight.operations Quality Assurance the FAA had.problems that if they require the.collection of data they cannot allow the.non-punitive in other words if they.require the collection of data and there.is information on there that reveals a.violation of FAA rules the FAA is.obligated to then issue a violation to.that pilot or carrier that goes at odds.with the principles of flight operations.quality assurance that there should be.no punishment for revealing a safety.problem we still believe that the FAA.should have gone to Congress and sought.the authority that would have allowed.the non-punitive reporting of required.data our representatives on Capitol Hill.decided that the FAA would not do that.and in the FAA reauthorization of I.believe 2012 they told the FAA they.could not do that those recommendations.there's over classified closed.reconsider that's unfortunate because I.think in this environment of compliance.versus enforcement we'd probably get a.lot farther now one last question on.page 36.it says the PIO I said he'd never done.an enroute inspection on trans-pacific.or any 135 operator he stated it would.be difficult to schedule that he'd have.to pay for a return flight and he stated.that you never really know if pilots.were complying with SOPs for every.flight so I posed I guess a general.in here how can the FAA effectively.monitor what's going on with 135 so a.lot of these airplanes don't have jump.seats particularly the smaller ones and.so forth any thoughts on that well your.question actually alludes to the problem.in 1/35 many these smaller operators are.operating aircraft that like this one.doesn't even have a jump seat so you can.get anybody up there to really monitor.on a regular basis and that's really the.basis for us reiterating the.recommendations out of Akron to take a.more data-driven approach rather than.just a enroute jump see because that's.just a snapshot of what the operation a.data-driven approach like an FTM program.is a more comprehensive approach to.learning about what's going on on the.operation and that's that's what we.believe would benefit 135 operators like.this one thank you thank you very much.remember later do part 135 operators.exercise the loft process at all no.there's no requirement under 135 for.loft.do they voluntarily are there any.carriers or operators who voluntarily.incorporate loft I don't know the answer.to that there may be some that do.incorporate segments of loft in their.training but under 135 for 135 to 93 to.97 and 299 checks it's not required okay.by the way loft is line oriented flight.training for those who don't recognize.it we've we've talked about the flight.crews operation of the airplane.we've talked a bit about the status of.safety at the operator what kind of role.did the FAA play or could have played in.terms of mitigating this situation.avoiding the accident or week etc.from the investigation we found that the.operator similar to what we found in.Akron doesn't do any any inspections.they primarily rely on manual reviews.and things like that and they don't get.out because the logistical challenges.that have been alluded to earlier of.getting into the airplane of doing the.enroute inspections and again that's why.we're going down the FTM route so it's a.much more comprehensive if you don't.have to rely on the FAA to be in the.cockpit doing observation you can have.the operator learn about their operation.and develop an SMS program that's.comprehensive to incorporate some of the.issues that they see in the operation.and mitigate those at the operator level.now for several years the most wanted.list is included loss of control as a.one of the ten items this past year.that's been changed to include part 135.can you just comment on what the most.wanted list says in relation to part 135.operations I think as we've been talking.this morning we see a lot of instances.of 135 flights where there are issues.with non-compliance with standard.operating procedures the focus of the.most wanted list item is on several.things one is that SMS programs be.established for all the carrier's a big.part of SMS but something that can be.done is flight data monitoring that's.another one of the issues on the most.wanted list those two combined will.address many of the issues but seem to.be a common thread to all of these.recommendations with 135 that we've been.investigating over and over and over.Thank You mr. Marcus yield the balance.of my time Thank You member Winer number.comedy.so I think there were a lot of failures.at all levels in this accident.I think the crew clearly had significant.issues I think trans-pacific could have.identified problems and they didn't in.fact I will note that in Appendix B.trans-pacific in a submission to NTSB.dated March 1st 2018 they submitted a.number of actions that they plan to.implement in response to the accident.which includes expediting full.implementation of a safety management.system which is something that we've.encouraged in a number of accidents and.that's a good thing except on the same.date they filed comments in the public.docket which points solely at problems.with the crew and fails to recognize.that they could have identified unsafe.operations among their crew and and.that's a concern I think safety.management is starts from the top and if.you can't realize recognize your.failings that's a significant issue but.there were also some problems with FAA.too which have been noted do most part.121 operations have flight data.monitoring programs most 121 s do have a.form it's called folk light operations.Quality Assurance and those are data.driven approaches that are on the 121.level those are pretty much formal.they're voluntary and ICAO annex 6 for.international operations actually.requires 121 operators to have a focal.program or flight to add a monitoring.program to land in certain countries but.it's not required in the United States I.was going to ask if they were voluntary.and have we recommended that we've.recommended before in past accidents.that part one 135 have flight data.monitoring right can you talk about some.of those accidents you have briefly.mentioned a couple of times.grinning there are a lot of similarities.between Akron and what happened here.maybe you could talk about that a little.bit are you asking what happened in.Akron that similar are you asking for.other 135 either one well we we had a.list of 15 accident I'm sorry.seven accidents involving 135 on them.and that's not all 135 is just one 35.similar to this operator of where.somebody would charter an airplane to.carry people they were those 7 accidents.occurred over a 15 year period of time.and we were able to devote the resources.to go and do the in-depth investigation.necessary to uncover all of the problems.with pilot performance so those are not.all 135 accidents during that 15 year.birthday time those are just the ones.that we chose for special processing to.get into it to fully understand what was.happening among those accidents there.was Akron there was an accident in.Owatonna Minnesota where a charter jet.was landing on a runway and after they.touched down during a raging.thunderstorm while they were midway down.the runway the pilot decided to try and.abort the landing and take off at the.middle of the runway and overran the.runway and killed everybody.there was a very prominent accident in.2002 in Eveleth Minnesota involving a.beach king hair there was a prominent.citizen on that airplane but the pilots.were not well trained they showed very.poor crew resource management they had a.whole variety of problems and they.botched the landing and killed everybody.on that airplane there was an accident.and also at Teterboro in 2005 where an.airplane was going down the runway.because the pilots had not checked to.make sure that it was properly loaded.the center of gravity was too far.forward and the airplane was unable to.rotate takeoff it went over the end of.the runway and ran into a warehouse that.was just beyond the runway at Teterboro.air what.that killed it was more than a year.after the accident but ultimately one of.the passengers in the car that the.airplane hit as it was crossing the.runway to run into the warehouse died.the pilots the second-in-command of that.airplane was not even qualified to be on.a 135 flight there's those are just a.few examples ok thanks and one last.question because I only have a few.seconds why is important for why is it.important captain Lawrence to adhere to.standard operating procedures talking.about standard operating procedures like.in this case the use of checklists the.use of flying profiles the CRM the.communication all these things in a.professional cockpit a professional.cockpit is is like a choreographed song.it's choreographed and it should sound.the same the tune is the same every.flight is the same it's just the the.performers who are different so adhering.to SOPs is not just a it's not just a.catchphrase it's something that is.critical to the safety we've cited it in.multiple like what mr. Marcus just said.cited in multiple accidents that failure.led to either a fatal event or some type.of accident it's also important to note.that strict adherence to SOPs can save.lives this board just adopted a report.that went publish it on the epsilon II.accident were the overrun on a rejected.takeoff that occurred because the.airplane was not flyable it was broken.and there was a chairman in the right.seat and had he tried to take over which.would have been against his SOPs and.tried to attempt to take the airplane.off would have led to a greater loss of.life but he is strictly adhere to the.SOPs by maintaining his pilot monitoring.duties and likely saved lives there so.it's not a catchphrase doing the SOPs.and adhering to him every time it's.safety critical for pilots did it here.thank you very much so the captain.Lawrence let's talk about prior failures.checkride failures do you remember how.many noses no prior jack rod failures.and we're talking about faa checkride.failures the captain had and this won't.happen i believe had two or three.certification ride failures one of which.was notably as a flight instructor.certificate yeah he had three and how.about the second officer he had two.that's right so i've spent a good bit of.yesterday going through previous.accident reports now bear in mind that.NTSB does not do a board meeting for.every accident that we investigate so we.call the ones that we do investigate and.publish report thick report on olden.days term but we call them blue cover.reports at least that's what i still.call them so i went through a number of.blue cover reports yesterday involving.part 135 operators where there had been.previous failures air sunshine in 2004.scheduled part 135 passenger commuter.the pilot command had nine prior check.ride failures marlin air cessna citation.crashing to Lake Michigan in 2007.part 135 the captain had a poor training.record previous failures global exec a V.a tional Lear Lear 60 in Columbia South.Carolina part 135 the captain had four.prior failures execu flight part 135.flight poor performance poor prior.performance and now this one so mr..Marcus you and I spoke about this.yesterday in 2005 the NTSB came out with.a recommendation.AO 527 can you describe what that.recommendation is and what it means I.think there were actually three.recommendations issued in 2005 there.were two issued as a result of the year.sunshine accident.we're talking about one of them asked.that the FAA obtain notices of.disapproval and Chuck right I'm sorry.that airlines when they hire a pilot.would obtain records of flight check.failures of the people they were.considering the FAA said that they will.be including that in their pilot records.database when that rule is issued we.also asked them to do a study to see if.the number of flight check failures in a.pilot's record was indicative of the.future risk of an accident.we believed based on when I'll be.talking about in a second with a Oh 527.there were indications that it would the.FAA did a study they concluded from.their study that there was no predictive.value from that a oh 527 was issued as a.result of a study that we did of general.aviation accidents that were caused by.weather issues mm-hmm as part of the.analysis for that study we found that.there seemed to be a fairly predictive.value of a pilot being involved in a.weather-related accident based on the.number of checkride failures in the past.we thought that there was pretty clear.statistical evidence from our analysis.we asked the FAA to evaluate that and.act on that the FAA in 2014.told us that they had done a study they.did not look at flight check failures.they looked at where the pilot received.their training and they found that there.was no correlation with where the pilot.received their training in future risk.but they also identified limitations in.the data and they said that they would.be improving the data to do a better.analysis as a result of that as a result.of their indications they would be.improving their data resources we.classified that recommendation open.acceptable pending the results of that.they have just recently sent us a letter.which is currently being evaluated by.the board in which the FAA said that.they decided to not do the analysis not.do the improvements in data collection.that their study had said were needed.but they believe that their voluntary.actions with the general aviation join.Safety Committee would take care of it.at this point we will probably be.closing the recommendation but we have.not yet the board has not yet made a.determination thank you and and captain.Lawrence or maybe mr. Marcus this.clarify this for me mr. Marcus mentioned.that so Priya does not currently address.prior certificate action of certificate.rides is that correct.it doesn't look at something I can't.remember what it does look at FAA.certification background it's part of.the Priya okay thank you.remember whiner for other questions none.thank you it would seem like the.training organizations play a fairly.important part in in all of this and I.just wonder this captain this was his.first P I see job is that correct and.we've noted that he lacked leadership.skills in this area I wonder if it makes.sense to make recommendation to the.training organizations to include a.leadership module for new captain's.thoughts we have a recommendation out of.the Colton accident that the FAA require.leadership training for people who were.being made captain the FAA and and that.recommendation was included in a.congressional mandate to the FAA to.adopt that rule that is currently.pending notice of proposed rulemaking.from the FAA which I believe they have.recently put on their website of.significant rule makings they plan to.issue sometime in 2019 but that.rulemaking would include an advisory.circular with guidance on training for.leadership for upgrading captain.okay doesn't sound like they've adopted.it yet thank you.a further question sir Anwar Hamid II.what was the company's stabilized.approach criteria in its standard.operating procedures they're defined.basic staple approach criteria said that.the aircraft had to be stable by a.thousand feet aligned with the landing.runway by five hundred feet there were.also multiple other elements of that.they had to be within 10 knots of.airspeed target airspeed configured for.the approach fully configured gear down.flaps full and one of the other elements.of this particular operator because.stable approach criteria or developed by.the at the operator level so one of the.things they said was that all checklist.and briefings needed to be completed be.considered stable and what should have.occurred once the crew realized the.approach wasn't stabilized the same.thing as we've seen in many other 135.like Akron and the others they should.have gone around I know staff are.proposing a safety alert on this issue.can you share why it's important for the.aviation community stabilized approach.is not just for 135 to 121 every pilot.that's flying an airplane should be.landing via a stable approach and since.the safety alert is identifying not just.this accident but multiple other.accidents to convey that this is not.just an operator level or 121 135 that.all pilots need to be stable thank you.thank you very much.so mr. Burt's you've been sitting there.very quietly so as I recall thus that we.computed that you computed the stall.speed of this aircraft in that.configuration to be around we're a.hundred and two knots hundred and one so.there yes sir and but the slowest.slowest speed derived from radar was a.hundred and eleven degrees.I'm sorry 100 hundred eleven knots but.they were in a 35 degree Bank angle.according to your study so oh and the.hundred 101 102 that we just mentioned.about that was compensated for for the.for the bank angle the load factor.associated with the Bank incorrect so.what's the difference between the.hundred and eleven and a hundred and two.what did you account for that difference.about nine knots yeah okay very good.like I said there is no such thing as a.simple math but can you elaborate on so.we we believe the the aircraft stalled.aerodynamically still we do chairman.things that that that 102 doesn't.account for and goes back to that gus.factor half the Gus factor if you have a.sudden gust and it takes and it changes.the velocity of the air around the wing.you can quickly find yourself below.stall speed so that was probably part of.it and then the other part is they were.making a a fairly steep turn to final.base to final turn.so those control inputs would also.change the camber of the wing and and.the stall speed of each wing so I think.that's the other half of the pie amazing.so you were able to get compute the.speeds using radar data yes sir and and.I think maybe perhaps even the EGPWS yes.we use both yeah you know correlated.those and then Don provide its weather.information that you know took the radar.to two air speeds.well thanks thank you very much really.good work and mr. Eicke you've been.sitting there quietly as well and and so.there the winds were very gusty as we.heard in 16 minutes before the crash.there was a pilot report of an aircraft.on approach to LaGuardia which is fairly.close of wind shear I think it was a.20-month 20 not loss it's 700 feet so.any any weather weather factors here any.possibility when she.for this particular crash yes there was.a you know numerous reports of wind.shear across the area and that's where.again the the whole premise of standard.operating procedures getting a weather.briefing being aware of wind shear when.they turn to ADIS the latest frequency.would have told them low level wind.shear advisories are in effect if they.had added the additional speed as.recommended they would have been able to.at least have a a margin over the low.level wind shear that was being reported.across the area thank you very much.finally regarding SMS captain Lawrence.SMS is it is it just best for large.operators or can it be scalable the FAA.is actually indicated and provided.guidance in presentations that SMS is.scalable at any level any operator.single airplane single pilot all the way.up to the major airlines can incorporate.SMS do we have any idea at all probably.not because we're primarily an accident.investigation agency do we have any idea.at all.what percentage of part 135 operators.actually are incorporating SMS I have.that information sir great thank you.are there any further questions from my.colleagues great then let's take a break.let's come back at 11:15 we are in.recess.well we'll begin in about one minute.we are back in session are there any.further questions or comments from my.colleagues two things I'd like to say.before we get into reading the findings.and I did make this point in my opening.statement fact of the matter is there.are a lot of 135 operators out there.that do a really fine job but we at the.NTSB by design we look at those that.don't turn out very well.and that's our universe and our entire.purpose for doing these investigations.is frankly so that we can make.recommendations to further improve the.safety of operations so another thing I.wanted to to read that I meant to read.when I was talking about a record of.previous failures in a recommendation.letter that we issued in 2005 we talked.about check rod flight check failures.and it says the safety board recognizes.that one notice of disapproval for a.flight check along with an otherwise.successful record of performance should.not adversely affect the hiring decision.however the board also recognizes that.multiple notices of disapproval for a.flight check might be significant.depending on the reason for the.disapproval notices so I did want to.make that point I think that anyone can.can fail a check ride at any point I.hate to say this publicly but when I was.18 years old I failed my instrument.check ride on the first try but guess.what I had 50 check rides literally 50.check rides after that and managed to.slip through them so one check ride.failure is probably not Indic indicate.of indicative of a major problem when.you have nine or four or whatever that.that might be something an issue there.okay well if there are no further.comments mr. Slyde zyk if you'll kindly.read the proposed findings.thank you sir as a result of this.investigation staff proposes 17 findings.number one the flight crew was properly.certificated there was no indication.that the flight crew was impaired by.medical conditions alcohol or other.drugs and there were no pre-impact.airplane anomalies that would have.precluded normal operation number two.the pilot in commands pre-flight.planning was inadequate and incomplete.number three the flight crew members.failure to verify the approach and.conduct an approach briefing resulted in.confusion and errors that led them to.mismanage the vertical profile for the.approach and not initiate the circle.tool and maneuver according to air.traffic control instructions number four.the pilot in commands inadequate and.incomplete pre-flight planning and the.flight crews a lack of an approach.briefing contributed to the crews.confusion and lack of situational.awareness during the accident flight.number five the pilot in commands.decision to allow the second-in-command.to act as pilot flying was improper and.contrary to company standard operating.procedures number six the pilot in.commands extensive coaching of the.second-in-command and the PI and his.pilot flying duties distracted the pilot.in command interfered with the normal.division of pilot flying and pilot.monitoring duties and degraded the.flight crews overall performance number.seven the pilot in commands decision to.continue the approach was inappropriate.because the approach did not meet the.company's stabilized approach criteria.and the airplane was not in a position.to make a safe landing number eight the.piloting commands focus on the visual.maneuver of aligning the airplane with.the landing runway distracted him from.multiple indications of decreasing stall.margin resulting in an aerodynamic stall.at low altitude number nine a flight.data monitoring program can help title.14 Code of Federal Regulations part 135.operators identify and mitigate.procedural non-compliance including the.operational deficiencies identified in.his accident investigation number 10.because the Federal Aviation.Administration was not conducting checks.in a manner that allowed observation of.routine flight operations the FAA could.evaluate trans-pacific jets pilots nan.cookers excuse me pilots compliance with.standard operating procedures during.these operations number eleven a safety.management system would have improved.trans-pacific jets ability to identify.and mitigate risks because a safety.management system requires operators to.incorporate formal system safety methods.into their internal oversight programs.number 12 effective oversight procedures.within the safety assurance system would.help the Federal Aviation Administration.identify operators that do not insure.flight crew compliance with standard.operating procedures number 13.the pilots performance on the accident.flight included deficiencies that were.noted during their initial during their.initial trans-pacific jet training but.the company did not monitor the pilots.subsequent performance to identify and.correct any continued deficiencies.number 14.although trans-pacific Jets crew.resource management or CRM training.program complied with the requirements.of title 14 Code of Federal Regulations.one thirty five point three three point.three three zero the Federal Aviation.Administration had not provided adequate.guidance for 14 CFR part 135 operators.to develop and implement effective CRM.training programs consequently.trans-pacific training did not result in.the flight crew effectively using CRM to.mitigate safety risks number 15.specific leadership training provided to.title 14 Code of Federal Regulations.part 135 and 91k pilots at the time of.upgrade to pilot in command would help.standardize and reinforce critical.command authority skills and improve.flight safety number 16 because the.company did not have a Learjet qualified.management pilot kerchak Airmen on staff.during the accident second in commands.or si C's period of employment.trans-pacific jets graduated s IC.qualification policy could not provide.him at other company Learjet SICS a.viable well-structured path to gain.experience as pilot flying and lastly.number 17.including.the manufacturer recommended approach.speed wind additives and operations.manuals for Learjet 35 a airplanes could.reduce the risk of a stall by requiring.pilots to increase the approach speed.and weather conditions conducive to.rapid and possibly unexpected when.changes thank you mister Slezak.are there any amendments saying none do.I have a motion to approve the findings.as presented second then moved by member.wayno second seconded by vice chairman.Landsberg is there any discussion seeing.none all in favor of adopting the.findings as presented please signal with.a hand and say aye.opposed there are none the motion.carries unanimously.mr. Slezak if you'll please read the.probable cause yes sir.staff proposes the following probable.cause the National Transportation Safety.Board determines that the probable cause.of this accident was the pilot in.commands RP ICS attempt to salvage an.unstabilized visual approach which.resulted in an aerodynamic stall at low.altitude contributing to the accident.was the Pisces decision to allow an.unapproved second-in-command to act as.pilot flying the Pisces inadequate and.incomplete pre-flight planning and the.flight crews lack of an approach.briefing also contributing to the.accident were Trans Pacific Jets lack of.safety programs that would have enabled.the company to identify and correct.patterns of poor performance and.procedural compliance and the Federal.Aviation Administration's ineffective.safety assurance system procedures which.failed to identify these company.oversight deficiencies thank you are.there any proposed amendments there are.none do I have a motion to adopt the.probable cause as proposed so moved.has been moved by the vice chairman and.seconded by member Hama deep well there.is there any discussion all in favor.seeing none all in favor of adopting the.probable cause as proposed.please signal with a hand and say I.oppose there are none so the probable.cause is adopted unanimously as far as.the recommendations are concerned mr..Slezak if you'll please read those yes.sir we have three new recommendations.and six reiterated recommendations the.new recommendations all go to the.Federal Aviation Administration number.one require all title fourteen Code of.Federal Regulations part 135 operators.to establish programs for flight crew.members who have demonstrated.performance deficiencies or experience.failures during training and administer.additional oversight and training to.address and correct performance.deficiencies second recommendation.develop guidance for title 14 Code of.Federal Regulations part 135 operators.to help them create and implement.effective crew resource management.training programs and the last.recommendation to the FAA review.operators Learjet 35 a operations.manuals to determine whether they.contain manufacturer recommended.approach speed wind additives and.encourage those operators without that.information to add it to their.operations documents and I'll now read.the reiterated recommendations six of.them which are again all to the Federal.Aviation Administration recommendation a.- 10 13 issue an advisory circular with.guidance on leadership training for.upgrading captain's at 14 Code of.Federal Regulations part 121 135 and 91k.operators including methods and.techniques for effective leadership.professional standards of conduct.strategies for briefing and debriefing.reinforcement and correction skills and.other knowledge skills and abilities.that are critical for air carrier.operations second reiterated.recommendation is a 10-14 require all 14.Code of Federal Regulations part 121 135.and 91k operators to provide a specific.course on leadership training to their.upgrading captain's that is consistent.with the advisory circular requested and.safety recommendation a - 1013 safety.recommendation aid.16 - 34 require all 14 Code of Federal.Regulations part 135 operators to.install flight and data recording.devices capable of supporting a flight.data monitoring program the safety.recommendation a - 16 - 35 after the.action and safety recommendation a - 16.- 34 is completed require all 14 Code of.Federal Regulations part 1 35 operators.to establish a structured flight data.monitoring program that reviews all.available data sources to identify.deviations from established norms and.procedures at other potential safety.issues safety recommendation a - 16 - 36.require all 14 Code of Federal.Regulations part 1 35 operators to.establish safety management system.programs and lastly safety.recommendation a - 16 - 41 review the.safety assurance system and develop and.implement procedures needed to identify.14 Code of Federal Regulations part 1 35.operators that do not comply with.standard operating procedures thank you.and as I understand it - mister Slezak.we are reclassifying recommendation a 16.- 41 is open unacceptable response that.is correct serious thank you very much.are there any any proposed amendments do.I have a motion to adopt the let me ask.a question if I may.thank you on recommendation 3 we say we.require operators of Lear 35 require the.operators Lear 35 a operations manuals.to determine whether they have the.appropriate speed additives in there why.didn't we single out the 35 a there are.a lot of other there's other Lear Jets.out there there's other airplanes why.did we single out that airplane.not singling it out but we did in this.accident only look at the Lear 35 a so.we discovered it wasn't in the.operations manual so that why is why we.only address the 35 a yes and I also.raised that question when I wrote my.memo and staff did specifically comment.because I did raise that and that we.have seen a number of accidents actually.involving an uncommanded roll with the.35 a1 of merit merit Marianna Florida.nashville tennessee Goodland Kansas.provost and excuse me Prospect Heights.Illinois so we have we've actually seen.accidents involving this particular.model due to a roll-off due to improper.speed thank you okay do we have a motion.to adopt the recommendation.recommendations as presented remember.Waner has adopted our excuse me has.motioned to adopt the recommendations.and remember Hammond D has seconded any.further discussion.any discussion seeing none all in favor.of adopting the recommendations as.proposed.please signal with a hand and say aye.opposed there are none the.recommendations are adopted unanimously.does anyone have any additional issues.for discussion at this point does anyone.have a motion to adopt the report as.presented the vice chairman has moved so.moved.member wayno has seconded any discussion.all in favor of adopting the report as.presented please signal with the hand.and say aye.opposed there none the report has been.adopted unanimously any members wish to.reserve the right to file a concurring.or dissenting statement okay.so in closing I want to thank the staff.for your hard work I think this was a.very good investigation I think that.there are some very good recommendations.have come out of this report I want to.thank my colleagues for preparation for.this meeting going into meeting as we.meet one on one one on one we meet with.staff ahead of time to discuss the.report we write memo is accordingly so I.want to thank you for for your.preparation going into the board meeting.and for the good good debate and.discussion today my special thanks to.you Jim Jim Sullivan just served as the.investigator in charge but as I often.say here nothing gets done by just one.person alone it takes a team and that's.sincere thank you not only to the.investigative team but to the to.everyone else the support staff and the.program staff as well who support our.efforts finally I want to thank the the.first responders and the other public.servants from Bergen County New Jersey.from the boroughs of karlstad and E.through East Rutherford New Jersey thank.you all for your help and thank you for.being here today so that we could thank.you all of your good support also want.to thank the Port Authority of New York.and New Jersey for their truly exemplary.support and cooperation on scene each.time you take apart 125 121 flight you.benefit from safety programs that can.and should be extended to part 135.operations the recommendations just.issued if acted upon will help to close.that gap the recommendations reiterated.today are just as just as important the.NTSB continues to support a single high.level of safety in aviation we stand.adjourned.

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